8. Canine and Feline Anesthesia

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  • Chapter 2 covers patient preparation in detail.
  • Physiologic abnormalities that need to be corrected include dehydration, hypotension, and anemia. A single, standard protocol does not fit all patients. The protocol must be developed based on the patient. Standard protocols can be used as a starting point. It is always good to have two people check the calculated doses. Make sure the drug concentration used to calculate the dose is the same concentration drawn into the syringe.
  • Reversal drugs are available for opioids, benzodiazepines, and alpha 2 -agonists.
  • The anesthetist cannot control the duration of or decrease the depth of the anesthetic.
  • The tube must be clean, sanitized, and free of blockages and holes. Also check the tube for integrity, deterioration, or other damage.
  • Adjust the vaporizer and oxygen flow to get the patient to a surgical level. When the patient has reached that level decrease the vaporizer setting and continue monitoring.
  • If the tube is placed in the esophagus instead of the trachea, no anesthetic will reach the lungs and the patient won’t remain anesthetized.
  • These procedures can be used to maintain general anesthesia after a patient has undergone induction and intubation and has been brought into surgical anesthesia. Inhalation anesthetic machines are most commonly used to maintain general anesthesia. No matter what method is used to maintain anesthesia, the patient must be monitored at all times to make minor or major adjustments to the level of anesthesia.
  • Monitoring a patient after anesthesia is something that must be done continuously and at close range. The anesthetist must be prepared to react immediately to whatever the recovering patient presents, whether that is normal extubation or an emergency situation.
  • 8. Canine and Feline Anesthesia

    1. 1. Canine and Feline Anesthesia General Anesthesia Sedation Neuroleptanalgesia Local and Regional Anesthesia Chapter 8
    2. 2. Patient Preparation <ul><li>Don’t take shortcuts </li></ul><ul><li>Don’t skip steps </li></ul><ul><li>Incomplete patient preparation can result in life-threatening consequences </li></ul>
    3. 3. Selecting an Anesthetic Protocol <ul><li>The list of anesthetics and adjuncts prescribed for a particular patient </li></ul><ul><ul><li>Includes calculated dosages, routes, and order of administration </li></ul></ul><ul><ul><li>Selected by the veterinarian-in-charge </li></ul></ul><ul><ul><li>Calculate, check, and recheck drug doses, oxygen flow rates, and fluid administration rates </li></ul></ul><ul><ul><li>Takes into account minimum patient database, patient physical status, and procedure </li></ul></ul><ul><ul><li>Modified protocol for ill, pediatric, or otherwise compromised animals </li></ul></ul>
    4. 4. Minimize Adverse Effects of Anesthesia <ul><li>Correct physiologic abnormalities prior to anesthesia </li></ul><ul><li>Base the protocol on the results of the patient’s minimum database </li></ul><ul><li>Use a balanced protocol consisting of multiple agents </li></ul><ul><li>Double-check all injectable drug doses prior to administration </li></ul><ul><li>Label all syringes with the patient name, drug name, and drug concentration </li></ul><ul><li>Administer no more than the minimum dose needed to achieve the desired level of anesthesia </li></ul><ul><li>Administer all IV agents “to effect” unless told otherwise </li></ul>
    5. 5. General Anesthesia: IM Induction <ul><li>Anesthetic agents are administered by intramuscular (IM) injection </li></ul><ul><li>Anesthetic depth gradually increases, peaks, and gradually decreases </li></ul><ul><li>After injection the anesthetist has little control over the anesthesia </li></ul><ul><ul><li>May administer more anesthetic if adequate depth is not reached </li></ul></ul><ul><ul><li>If a reversal drug is available for the anesthetic agent, it can be administered if patient is too deep </li></ul></ul>
    6. 6. Induction with an IM Agent or Combination
    7. 7. General Anesthesia: IV Injection and Ultra–short-acting Agent <ul><li>Technique used for short procedures </li></ul><ul><ul><li><10 minutes of anesthesia </li></ul></ul><ul><li>Drugs: </li></ul><ul><ul><li>Propofol, methohexital, thiopental sodium, or etomidate </li></ul></ul><ul><li>Drug is given to effect </li></ul><ul><li>Anesthetic depth increases rapidly then decreases gradually </li></ul><ul><li>Anesthetist controls peak effect and can increase depth by administering more anesthetic agent </li></ul>
    8. 8. Induction with an IV Injection of an Ultra–short-acting Agent to Effect
    9. 9. General Anesthesia: TIVA and Ultra–short-acting Agent <ul><li>TIVA: Total intravenous anesthesia </li></ul><ul><li>Patient is induced to effect; additional boluses are administered every 3-5 minutes as needed to maintain surgical anesthesia </li></ul><ul><ul><li>Short-to-moderate length noninvasive procedures </li></ul></ul><ul><ul><li>Propofol is the most commonly used agent </li></ul></ul><ul><ul><li>Anesthetist can increase depth but can’t decrease depth if excessive </li></ul></ul>
    10. 10. Total Intravenous Anesthesia (TIVA) by IV Boluses of an Ultra–short-acting Agent
    11. 11. General Anesthesia: TIVA by CRI <ul><li>Total intravenous anesthesia by constant rate infusion (CRI) </li></ul><ul><li>Patient is induced to effect </li></ul><ul><li>Anesthesia is maintained by constantly infusing small amounts of anesthesia via a syringe pump </li></ul><ul><ul><li>Slows down and moderates changes in depth as seen with bolus administration </li></ul></ul>
    12. 12. Total Intravenous Anesthesia by Constant Rate Infusion
    13. 13. General Anesthesia: Inhalant Agent <ul><li>Not an injection technique </li></ul><ul><ul><li>Induction is faster than IM induction, but slower than IV induction </li></ul></ul><ul><ul><li>Anesthetist has control over depth of the anesthesia; can make changes rapidly </li></ul></ul><ul><ul><li>Delay between time dial setting is changed and patient depth occurs </li></ul></ul><ul><li>Factors that affect delay time </li></ul><ul><ul><li>Patient respiratory drive </li></ul></ul><ul><ul><li>Agent used and carrier gas flow rate </li></ul></ul><ul><ul><li>Type and volume of breathing circuit </li></ul></ul>
    14. 14. Induction and Maintenance with an Inhalant Agent
    15. 15. General Anesthesia: IV Induction and Inhalant Maintenance <ul><li>Most commonly used method of inducing and maintaining anesthesia in small animals </li></ul><ul><li>Dynamic elements of both IV and inhalant administration </li></ul><ul><ul><li>Rapid induction </li></ul></ul><ul><ul><li>Good control over both increases and decreases in anesthetic depth </li></ul></ul><ul><ul><li>Rapid recovery </li></ul></ul>
    16. 16. IV Induction and Maintenance with an Inhalant Agent
    17. 17. Equipment Preparation <ul><li>Locate, check, and prepare all equipment needed for entire anesthetic period prior to induction </li></ul><ul><ul><li>Intubation equipment </li></ul></ul><ul><ul><li>Syringes, needles, drugs, fluids required </li></ul></ul><ul><ul><li>Equipment designed to prevent hypothermia </li></ul></ul><ul><ul><li>Small animal anesthetic machine </li></ul></ul><ul><ul><ul><li>Semiclosed rebreathing system (≥2.5 to 3 kg patient weight) </li></ul></ul></ul><ul><ul><ul><li>Non-rebreathing system (<2.5 to 3 kg patient weight) </li></ul></ul></ul><ul><ul><li>Crash cart with emergency drugs and equipment </li></ul></ul>
    18. 18. Premedication or Sedation <ul><li>Calms the patient and prepares the patient for anesthetic induction </li></ul><ul><li>Desired effects </li></ul><ul><ul><li>Sedation, cholinergic blockade, analgesia, muscle relaxation </li></ul></ul><ul><li>Drugs </li></ul><ul><ul><li>Tranquilizers, alpha 2 -agonists, opioids, dissociatives, anticholinergics </li></ul></ul>
    19. 19. Premedication or Sedation (Cont’d) <ul><li>After IM injection place the animal in a quiet yet accessible place </li></ul><ul><ul><li>Close observation until agent takes effect </li></ul></ul><ul><ul><li>Stimulation or excitement may diminish the beneficial effects </li></ul></ul><ul><li>Induction should follow immediately after desired effects are reached </li></ul>
    20. 20. Anesthetic Induction <ul><li>Patient loses consciousness and enters surgical anesthesia </li></ul><ul><ul><li>Take the patient from consciousness to stage III anesthesia smoothly and rapidly </li></ul></ul><ul><ul><li>Intubate when possible while animal is still light </li></ul></ul><ul><ul><li>IV induction is most common and takes animals through the excitement stage most rapidly </li></ul></ul><ul><ul><li>Attempt to avoid the excitement/struggling stage, which is seen more often with mask induction </li></ul></ul><ul><ul><li>IM induction results in smooth, gradual CNS depression with little apparent time spent in the excitement stage </li></ul></ul>
    21. 21. IV Induction <ul><li>Drugs used </li></ul><ul><ul><li>Mixture of equal volumes of ketamine and diazepam or midazolam </li></ul></ul><ul><ul><li>Propofol </li></ul></ul><ul><ul><li>Neuroleptanalgesics </li></ul></ul><ul><ul><li>Thiopental sodium </li></ul></ul><ul><ul><li>Etomidate </li></ul></ul><ul><ul><li>Various other combinations containing dissociatives, tranquilizers, and opioids </li></ul></ul>
    22. 22. IV Induction (Cont’d) <ul><li>Administer IV to effect (unconsciousness) </li></ul><ul><ul><li>Don’t administer the entire calculated dose all at once </li></ul></ul><ul><ul><li>Allow for individual patient response to anesthetic </li></ul></ul>
    23. 23. IV Induction (Cont’d) <ul><li>Premedication drugs can affect the dose of general anesthetic required </li></ul><ul><li>Titration </li></ul><ul><ul><li>IV drugs given as a series of bolus injections and discontinued when desired effect is reached </li></ul></ul><ul><li>IV induction produces up to 10-20 minutes of anesthesia </li></ul><ul><ul><li>If more time is needed, anesthesia is maintained with inhalation anesthetics or administration of propofol, methohexital, or etomidate by repeat boluses or CRI </li></ul></ul>
    24. 24. Inhalation Induction <ul><li>Anesthetic induction using a facemask or induction chamber </li></ul><ul><li>Drugs used: isoflurane and sevoflurane </li></ul><ul><ul><li>Low blood-gas solubility coefficient </li></ul></ul><ul><ul><li>Results in rapid passage through stage II anesthesia </li></ul></ul>
    25. 25. Inhalation Induction (Cont’d) <ul><li>Mask induction </li></ul><ul><ul><li>Use of a facemask to induce anesthesia </li></ul></ul><ul><ul><li>Requires skillful restraint to prevent patient or operator injury </li></ul></ul><ul><ul><li>Don’t restrict chest excursions or the airway </li></ul></ul><ul><ul><li>Fit the mask prior to induction </li></ul></ul><ul><ul><li>Mask obscures muzzle and eyes normally used for monitoring </li></ul></ul><ul><ul><li>Need higher oxygen flow rates than with endotracheal tube </li></ul></ul>
    26. 26. Inhalation Induction: Facemask <ul><li>Cautions </li></ul><ul><ul><li>Exposes personnel to waste anesthetic gas </li></ul></ul><ul><ul><ul><li>Need adequate room ventilation </li></ul></ul></ul><ul><ul><li>Patient struggling can lead to epinephrine release </li></ul></ul><ul><ul><ul><li>Use only on calm or sedated patients </li></ul></ul></ul><ul><ul><li>Longer induction period </li></ul></ul><ul><ul><ul><li>Avoid in patients with poor respiratory function </li></ul></ul></ul><ul><ul><li>Intubate immediately when possible </li></ul></ul><ul><ul><ul><li>To gain control of airway and ventilation </li></ul></ul></ul><ul><ul><li>Always keep airway open </li></ul></ul><ul><ul><ul><li>Don’t occlude nostrils or compress airway or chest </li></ul></ul></ul>
    27. 27. Inhalation Induction: Chamber <ul><li>Placing patient in a closed chamber infused with anesthetic gas </li></ul><ul><ul><li>Patient is usually <5-7 kg body weight </li></ul></ul><ul><ul><li>Used for small, aggressive patients </li></ul></ul><ul><li>Examine chamber prior to use </li></ul><ul><ul><li>Tight-fitting lid with two gas ports </li></ul></ul>
    28. 28. Inhalation Induction: Chamber (Cont’d) <ul><li>Complications </li></ul><ul><ul><li>Stress, trauma, vomiting, airway blockage </li></ul></ul><ul><ul><li>Hard to monitor patient </li></ul></ul><ul><ul><li>Exposes personnel to waste anesthetic gas </li></ul></ul><ul><ul><ul><li>Attach scavenger </li></ul></ul></ul><ul><ul><li>Epinephrine release </li></ul></ul><ul><ul><ul><li>Predisposes patient to cardiac arrhythmias and hypotension </li></ul></ul></ul>
    29. 29. IM Induction <ul><li>Neuroleptanalgesic combinations and a variety of combinations of tranquilizers, dissociatives, and opioids used to induce general anesthesia </li></ul><ul><li>Benefits </li></ul><ul><ul><li>Use in animals in which IV injections are difficult </li></ul></ul><ul><ul><ul><li>Young animals, aggressive animals, wild animals, captive animals in zoos </li></ul></ul></ul><ul><ul><li>May need restraint equipment, blowpipe, or tranquilizing gun </li></ul></ul>
    30. 30. IM Induction vs. IV Induction <ul><ul><li>The dose of a drug needed for IM induction is generally about twice the corresponding IV dose </li></ul></ul><ul><ul><li>IM induction takes longer to achieve high enough brain concentration to induce anesthesia </li></ul></ul><ul><ul><li>After peak effect of the IM drug is reached and the patient is still too light, an additional drug or inhalant agent must be administered to get the patient deep enough to intubate </li></ul></ul><ul><ul><li>IM induction results in a longer recovery period because of a longer metabolism time </li></ul></ul>
    31. 31. Endotracheal Intubation <ul><li>Endotracheal tube is placed in the patient’s airway after general anesthesia induction </li></ul><ul><ul><li>Conducts air or anesthetic gases directly from oral cavity to trachea </li></ul></ul><ul><ul><li>Bypasses the nasal passages and pharynx </li></ul></ul><ul><ul><li>Can be connected to an anesthetic machine to maintain anesthesia </li></ul></ul>
    32. 32. Endotracheal Intubation (Cont’d) <ul><li>Benefits </li></ul><ul><ul><li>Helps maintain an open airway </li></ul></ul><ul><ul><ul><li>Leave in place until the swallowing reflex returns </li></ul></ul></ul><ul><ul><li>More efficient delivery of anesthetic gas than facemask </li></ul></ul><ul><ul><ul><li>Decreased exposure of personnel to waste gas </li></ul></ul></ul><ul><ul><li>With inflated cuff helps prevent aspiration of vomitus, blood, saliva </li></ul></ul><ul><ul><li>Reduces anatomic dead space </li></ul></ul><ul><ul><ul><li>Improved efficiency of gas exchange </li></ul></ul></ul><ul><ul><li>Ventilation can be supported manually or mechanically </li></ul></ul><ul><ul><ul><li>Especially useful for patients in cardiac or respiratory arrest </li></ul></ul></ul>
    33. 33. Feline Intubation
    34. 34. Equipment for Endotracheal Intubation <ul><li>Three endotracheal tubes of slightly different diameters </li></ul><ul><li>Two-foot length of IV tubing or rolled gauze to secure tube </li></ul><ul><li>Gauze sponge to grasp tongue </li></ul><ul><li>12-mL syringe to inflate cuff </li></ul><ul><li>Good light source </li></ul><ul><li>Stylette for narrow diameter tubes </li></ul><ul><li>Lidocaine injectable solution or gel to control laryngospasm (cats) </li></ul><ul><li>Laryngoscope with appropriate blade </li></ul>
    35. 35. Intubation Equipment
    36. 36. Selecting an Endotracheal Tube <ul><li>Diameter </li></ul><ul><ul><li>Small enough to not cause trachea injury </li></ul></ul><ul><ul><li>Large enough to provide a seal with inflated cuff </li></ul></ul><ul><li>Length: minimize mechanical dead space </li></ul><ul><ul><li>Must reach the thoracic inlet </li></ul></ul><ul><ul><li>Must not extend beyond the end of the muzzle </li></ul></ul><ul><li>Patient </li></ul><ul><ul><li>Species, conformation, and breed </li></ul></ul><ul><li>Preparation </li></ul>
    37. 37. Proper Endotracheal Tube Placement
    38. 38. Intubation Procedure <ul><li>Know the anatomy of the throat </li></ul><ul><ul><li>Pharynx and larynx </li></ul></ul><ul><li>Know the proper restraint and positioning techniques </li></ul><ul><ul><li>Don’t attempt intubation unless you can visualize the larynx </li></ul></ul><ul><li>Have proper lighting </li></ul><ul><li>Induce patient with IV anesthetic </li></ul><ul><ul><li>Unconsciousness, no voluntary movement, no pedal reflex, sufficient muscle relaxation, no swallowing when tongue is pulled </li></ul></ul>
    39. 39. Anatomy of the Pharynx
    40. 40. Intubation Procedure <ul><li>Insert tube rapidly and correctly </li></ul><ul><li>Place patient in lateral recumbency </li></ul><ul><ul><li>Secure the tube and inflate the cuff </li></ul></ul><ul><ul><li>Turn on the oxygen </li></ul></ul><ul><ul><li>Attach the breathing circuit </li></ul></ul><ul><ul><li>Turn on the anesthetic vaporizer </li></ul></ul><ul><ul><li>Begin patient monitoring </li></ul></ul>
    41. 41. Endotracheal Intubation in Small Animals
    42. 42. Checking for Proper Tube Placement <ul><li>Revisualize larynx and confirm the tube is in the correct location </li></ul><ul><li>Watch reservoir bag as animal breathes </li></ul><ul><li>Feel for air movement from the tube connector as patient exhales </li></ul><ul><li>Fogging of the tube during exhalation </li></ul><ul><li>Unidirectional valve motion </li></ul><ul><li>Palpate the neck </li></ul><ul><li>Ability of patient to vocalize indicates misplaced tube </li></ul><ul><li>Patient coughs during intubation </li></ul><ul><li>Capnometer connection </li></ul>
    43. 43. Laryngospasm <ul><li>Reflex closure of the glottis in response to contact with an object or substance </li></ul><ul><ul><li>Common in cats, swine, and small ruminants in light plane of anesthesia </li></ul></ul><ul><ul><li>Makes intubation very difficult; larynx is easily damaged </li></ul></ul><ul><ul><li>May lead to cyanosis or hypoxemia </li></ul></ul>
    44. 44. Laryngospasm (Cont’d) <ul><li>Prevention </li></ul><ul><ul><li>2% injectable lidocaine or lidocaine gel </li></ul></ul><ul><ul><li>Adequate depth of anesthesia </li></ul></ul><ul><ul><li>Wait for glottis to open before intubating </li></ul></ul><ul><ul><li>Don’t force the tube </li></ul></ul>
    45. 45. Securing the Tube and Cuff Inflation <ul><li>Tie the ET tube securely without compressing the tube </li></ul><ul><li>Cuff the tube </li></ul><ul><ul><li>Extend the patient’s head </li></ul></ul><ul><ul><li>Have an assistant close the pop-off valve and compress the reservoir bag </li></ul></ul><ul><ul><li>Listen for gas leaks </li></ul></ul><ul><ul><li>Inflate the cuff until the leaking just ceases at a pressure of 20 cm H 2 O </li></ul></ul>
    46. 46. Complications of Intubation <ul><li>Vagus nerve stimulation </li></ul><ul><li>Brachycephalic dogs or other breed deformities </li></ul><ul><li>Overzealous intubation efforts </li></ul><ul><li>Overinflation of cuff </li></ul><ul><li>Obstructed endotracheal tube </li></ul><ul><li>Waiting too long to remove the tube </li></ul><ul><li>Improper cleaning and sanitizing between uses </li></ul><ul><li>Tracheal and/or laryngeal irritation leading to postsurgical cough </li></ul>
    47. 47. Maintenance of General Anesthesia <ul><li>Inhalant agent </li></ul><ul><li>Repeated boluses of ultrashort-acting agents </li></ul><ul><li>Continuous rate infusion (CRI) </li></ul><ul><li>Injectable and inhalant agents </li></ul><ul><li>Intramuscular injections </li></ul>
    48. 48. Patient Positioning, Comfort, and Safety <ul><li>Support the patient as it loses consciousness (especially the head) </li></ul><ul><li>Remove IV needle and syringe immediately after successful intubation </li></ul><ul><li>Lay patient in lateral recumbency immediately after intubation; then secure the tube and inflate the cuff </li></ul><ul><li>Ensure the endotracheal tube is inserted properly without bends or kinks </li></ul>
    49. 49. Patient Positioning, Comfort, and Safety (Cont’d) <ul><li>Temporarily disconnect tube when turning the patient </li></ul><ul><li>Support anesthetic machine hoses so no drag is put on the endotracheal tube </li></ul><ul><li>Check position of hoses and tube during transfer and repositioning </li></ul><ul><li>Make sure reservoir bag is visible at all times </li></ul><ul><li>Put animals in as normal a position as possible on the surgery table </li></ul>
    50. 50. Patient Positioning, Comfort, and Safety (Cont’d) <ul><li>Don’t use heavy drapes or instruments that will lie on the chest of small animals </li></ul><ul><li>Don’t overtighten leg restraints </li></ul><ul><li>Place patient on a heat-retaining surface </li></ul><ul><li>Place normal lung up if one lung is diseased </li></ul><ul><li>Be cautious of tilting the surgery table </li></ul><ul><li>Use artificial tears or other corneal lubricant </li></ul>
    51. 51. Anesthetic Recovery <ul><li>The period between the time the anesthetic is discontinued and the time the patient is able to stand and walk without assistance </li></ul><ul><li>Influencing factors </li></ul><ul><ul><li>Length of anesthetic period </li></ul></ul><ul><ul><li>Condition of patient </li></ul></ul><ul><ul><li>Type of anesthetic administered and route of administration </li></ul></ul><ul><ul><li>Patient body temperature </li></ul></ul><ul><ul><li>Patient breed </li></ul></ul>
    52. 52. The Anesthetist’s Role in Recovery <ul><li>Discontinue administration of anesthetic agents </li></ul><ul><li>Continually to monitor patient through the stages of recovery </li></ul><ul><li>Administer oxygen as necessary, especially to shivering patients </li></ul><ul><ul><li>Oxygen source placed close to the nostrils </li></ul></ul><ul><ul><li>Elizabethan collar and cellophane cover </li></ul></ul><ul><ul><li>Nasal catheter </li></ul></ul><ul><ul><li>Oxygen cage </li></ul></ul><ul><li>Administer reversal agents if available </li></ul>
    53. 53. The Anesthetist’s Role in Recovery (Cont’d) <ul><li>Maintain patent airway and extubate when appropriate </li></ul><ul><ul><li>Prepare by deflating cuff and untying gauze </li></ul></ul><ul><ul><li>Remove when the swallowing reflex returns (dogs, cats) or when signs of impending arousal are present (voluntary limb, tail, or head movements) </li></ul></ul><ul><ul><li>Remove the tube in one slow, steady motion </li></ul></ul>
    54. 54. The Anesthetist’s Role in Recovery (Cont’d) <ul><li>Provide general nursing care </li></ul><ul><ul><li>Quiet handling, calm reassurance, attention to patient comfort level </li></ul></ul><ul><ul><li>Prior to consciousness remove all restraint ties and make sure all accessory procedures are complete </li></ul></ul><ul><ul><li>Prior to consciousness remove all monitoring equipment, probes, cuffs, and electrodes </li></ul></ul><ul><ul><li>Be gentle when moving the patient </li></ul></ul><ul><ul><li>Leave IV catheter in place until recovery is complete </li></ul></ul>
    55. 55. The Anesthetist’s Role in Recovery (Cont’d) <ul><li>Provide general nursing care (Cont’d) </li></ul><ul><ul><li>Hasten recovery with gentle stimulation (talking, rubbing, gently move ET tube) </li></ul></ul><ul><ul><li>Turn every 10-15 minutes to prevent hypostatic congestion </li></ul></ul><ul><ul><li>Never leave patient unattended </li></ul></ul><ul><ul><li>Gradually rewarm hypothermic patients </li></ul></ul>
    56. 56. The Anesthetist’s Role in Recovery (Cont’d) <ul><li>Provide adequate analgesia and other prescribed medications </li></ul><ul><ul><li>Analgesics should be administered before the onset of pain </li></ul></ul><ul><ul><li>Adequate analgesia </li></ul></ul><ul><ul><ul><li>Patient sleeps comfortably with minimal signs of discomfort </li></ul></ul></ul><ul><ul><li>Dose adjustment or switching to a different analgesic may be necessary to control pain </li></ul></ul><ul><li>Prepare patient for ongoing hospital care or prepare patient for release </li></ul>

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